Background

Stress impacts both psychological and physical well being (1,2).
The preponderance of evidence linking stress and disease is based on the study of major
NLEs (3,4) utilizing checklist measures of commonly occurring major life
experiences which potentially have negative impact (i.e., death of someone close,
separation or divorce, financial loss, etc.). However, the association between NLE
frequency and health outcomes has been relatively modest, with life events accounting for
less than IO% of the variance. It has been suggested that, in part, this modest
explanatory power reflects the omission from existing NLE measures of both socially
controversial events (e.g., sexual abuse, abortion ) (5) and the
underrepresentation of life experiences more common to particular ethnic groups or a
particular social class (6). At the same time it has been long recognized that
such sociodemographic factors (i.e., belonging to an ethnic minority, living in poverty)
predispose individuals to particular pervasive forms of life stress (7).

One such obvious omission is the measurement of exposure to violence.
The degree of chronic life stress is significantly influenced by the characteristics of
the communities in which we live (8). Police-documented high crime rates (9)
and/or the perceived threat of crime and violence (10) are among unique
environmental factors purported to contribute significantly to the chronic stress of low
SES communities. Violent victimization is a major cause of morbidity in the United States
(US). True estimates are crude, but one national study estimated 6.2 million youth aged
10-16 years experience some form of completed assault or abuse per year; one of eight (2.8
million) experience an injury as a result; and one per one hundred (almost 250,000)
require medical attention (11). Crude statistics - such as arrest records and
murder rates - document the increase in the incidence of violence in American urban
communities (12,13). It is estimated for every lethality there are 100 assaults
(11). Rates of witnessing serious and lethal violence among inner-city youth
are also high. Studies in Detroit, Chicago, Boston, and New Orleans estimate that
approximately one-quarter of youth surveyed have witnessed someone shot and/or killed
during their lifetime (14,15) (16,17). One survey in an inner-city
public housing development in Chicago (mean age 11 years) found that 42% had seen someone
shot, 37% had seen someone stabbed, 21% lived with someone who had been shot and 16% lived
with someone who had been stabbed (17). Others indicate high frequency of
exposure at even younger ages. A study of children being evaluated at a pediatric clinic
at Boston City Hospital reported that one in ten children witnessed a shooting or stabbing
before the age of six (17).

In addition, national estimates of
domestic violence against women and children indicate widespread exposure to violence in
the home (18,19). In 1995, child protective services agencies investigated
reports alleging maltreatment of an estimated 3 million children (20). It is
currently estimated that between 2-4 million women are physically battered annually in the
US (18); 25-30% of all American women are at risk for domestic violence during
their lifetime (21). In the US, from 3.3 million (22) to 10 million
(23) children are estimated to witness parental violence annually. Witnessing
violence (24,25) may be as traumatic as direct victimization.

The operationalization of violence exposure introduces many challenges
currently facing investigators in the field. While most instruments include questions
regarding more severe events, such as shootings, being attacked with a weapon, or seeing
someone killed, few include questions regarding pervasive indicators of neighborhood
violence (i.e., drug sales, police arrests), sexual violence, psychological abuse,
domestic violence or stalking. Some measures include violence that is observed in the
media or ask about violent events that happen to both the subject and to others close to
the subject. Measures need to tap into both the nature and severity of traumatic exposures
as they are heterogeneous with potentially unique impacts on symptomatology (26,27).
This challenges the investigator to decide on the appropriate item content in exposure to
violence (ETV) instruments which may depend on both the population being studied and the
health outcomes of particular interest to the investigators. This lack of standardization
of the item content for ETV instruments also makes comparisons across studies difficult

Other contextual factors identified as potential mediators of the
impact of violence include an individuals' proximity to violence exposure (28),
timing of exposure to violent events (e.g., interplay of exposure on child development) (29,30),
chronicity of exposure, and the relationship of the subject to the perpetrator/victim (31).
Furthermore, children who are both direct victims and witnesses of violence may suffer
significant, yet distinct, emotional and developmental consequences (25,32,33).
Also, some evidence suggests that abused children may respond differently to witnessed
violence compared with children who are not abused (25,34). Although these data
suggest that it is important to distinguish whether violence exposure occurs in the home
or in the community and between violence that is witnessed and violence that is directly
experienced (victimization), many studies do not separate such events (35).

Thus a primary challenge in the field has been to develop an instrument
that contains items which cover a broad range of events in terms of context, severity, and
chronicity, and that separately address victimization and witnessed violence. Another
methodological limitation that has been raised is how the measures are scored to reflect
the level of ETV between subjects (36). At the same time, until recently
information on the psychometric properties of existing ETV instruments was sparse (37,38)
(39,40). This overview focuses on the more commonly used measure, those
instruments for which validity and reliability data are available, and measures which try
to address some of the methodological issues raised.

One of the most widely used measure
of ETV is the diagnostic criteria for Post Traumatic Stress Disorder (PTSD) (41).
This measure asks the subject whether they have ever had a terrible experience that
most people never go through like being attacked..... A total of nine classes of
events are included (e.g., military combat, rape, and seeing someone hurt or killed). The
measure is scored on a 0, 1 binary scale whereby if the respondent indicates that they
have experienced any one or more of the events, they receive a score of 1, if they have
experienced none of the events they receive a score of 0.

Another widely used measure, the Survey of Exposure to Community
Violence-Self Report Version (SECV-SR) (42) has minimal available psychometric
data on internal consistency (43). Kindlon et al. (36) have pointed
out that the SECV-SR, similar to most other ETV measures used, sum ordinal item responses
which are treated as falling on an interval scale. The SECV-SR uses a frequency scale
ranging from 0 (no exposure) to 8 (exposed every day). This approach assumes an interval
scale which necessarily requires that the increase in ETV impact between 0 (no exposure)
and 1 (exposed once) is the same as the increase in ETV impact between 7 (exposed once a
week) and 8 (exposed every day). These authors argue that no justification exists of equal
intervals between these ordinal scale points (36). They go on to point out an
additional scoring problem which lies in the equal weighting of items despite extensive
qualitative differences in item content. They provide the example that being the victim of
a knife attack would meet criteria for a traumatic event in diagnosing PTSD, whereas
witnessing illegal drug use or hearing gunshots would not. They underscore the issue that
with current methods, an individual reporting only a knife attack item would be
indistinguishable from one who had only heard gunshots - both would be scored as having
the same 'level' of ETV.

Existing ETV instruments that simply sum the total number of exposures
to a range of violent events lose information regarding the differential impact of
experiencing acute as opposed to chronic exposures as well. In response to these
recognized limitations, these investigators have applied existing mathematical modeling
techniques utilizing ETV ordinal response data to take into account frequency of exposure
and severity of events and have recently reported on the development of a structured
interview, My Exposure to Violence (My ETV) (a parent/caregiver-report version) (40).
This is a highly structured interviewer-administered instrument designed to cover a
subject's lifetime and past year exposure to 18 different violent events that have either
been witnessed or personally experienced by the subject. This also ascertains location of
violence (e.g., school, home, neighborhood), identifies both perpetrators and victims of
violence (e.g., family member, stranger), and whether the exposure has been gang-related.
The instrument measures lifetime exposure ('ever') and annual prevalence ('in the past
year'). Frequency of exposure is measured on a 6-point scale (never, once, 2 or 3 times, 4
to 10 times, 11 to 50 times, and more than 50 times). Six subscales are defined: 1) Witnessing
violent events, 2) Victimization, and 3) Total exposure (witnessing and
victimization) obtaining scores for both lifetime and past year exposure. These scales had
high internal consistency (r=0.68 to 0.93) and test-retest reliability (r=0.75 to 0.94).
These authors also provide evidence of construct validity.

This instrument is currently being used in the Program on Human Development in Chicago
Neighborhoods (PHDCN) (Felton Earls, PI). The PHDCN is sponsored by the John D. and
Catherine T. MacArthur Foundation, the National Institute of Justice, the National
Institute of Mental Health and the Department of Education. This study is the largest
prospective study (tracking 6000 children in 80 Chicago neighborhoods until 2003) aimed at
examining interrelationships of multiple social factors on mental health (PTSD) and
behavior.

We (RJ Wright) have developed an ETV instrument modified from two
sources including Richters' Survey of Exposure to Community Violence instrument (42)
and the Adult Witness to Violence Questionnaire developed by the group at Boston Medical
Center (Betsy Groves, personal communication). This instrument is the Witness to Violence
(WTV) questionnaire (unpublished). The adult/caregiver version gathers information on
experience of violence for both the adult and the child. The child version (for ages 8
years or older) asks the child directly. This has been administered in a face-to-face
interview setting. This questionnaire was structured to gather data on exposure to
violence (both direct victimization and witnessing violence), and like the My ETV
instrument (43), it ascertains location of violence (e.g., school, home,
neighborhood) and identifies both perpetrators and victims of violence (e.g., family
member, stranger). In addition, we obtain information on the seriousness of any injury
related to the violent event (e.g., broken bones, bleeding, death) and whether emergency
medical care was required. The 31-item scale was designed to broadly measure acts of
violence including hearing gunshots, witnessing slapping/hitting/punching, knife attacks,
and shootings. Adult/parent responders reported on these exposures for themselves as well
as for their children. Age of the child at the time of each recorded event is also
obtained. The instrument measures both lifetime exposure and within the past year. This is
currently being used in a longitudinal study of asthma morbidity in an inner-city cohort (44,45).

Cooley-Quille et al. (46) have recently reported the
reliability and validity of the Children's Report of Exposure to Violence (CREV) in an
inner-city population. The CREV is a self-report questionnaire composed of 32 items (29
rated on a 5-point Likert scale and 3 open-ended questions to indicate other violent
experiences not specifically asked about) assessing the frequency of lifetime exposure to
a variety of types of community violence (i.e., media, hearsay, direct witness, and direct
victimization for self, familiar persons or strangers). A score is derived by summing the
responses on the 29 scored items. These authors report good 2-week test-retest reliability
(r=0.75), internal consistency (Cronbach's a =0.78), and construct validity supporting
this as a sound brief self-report instrument for use in community violence research.

Hastings and Kelley (47) provide empirical evidence on the
utility of the Screen for Adolescent Violence Exposure (SAVE) in assessing adolescent
exposure to school, home, and community violence. This instrument was developed on 1,250
inner-city adolescents and obtained excellent reliability and validity. These authors
identified three subscales including Traumatic Violence, Indirect Violence, and
Physical/Verbal Abuse. The SAVE correlated significantly with both objective crime data
and theoretically relevant constructs (anger, posttraumatic stress symptoms, and
internalizing/externalizing problems). The SAVE does allow quantification of severity of
violence exposure by setting.

When assessing level of exposure to violence among children it may be important to get
both parental as well as self- (child-) reports. Studies of the impact of ETV on the child
primarily have relied on mother's report to document both the violence and the child's
response to it. Yet the mothers have oftentimes recently experienced violence themselves,
may be depressed/anxious, and may not be the most reliable reporters of the
events/sequelae (48). Parent-child agreement on exposure to violence in the
community may be moderate at best (40). In the instance of domestic violence,
many parents minimize or deny the presence of children during incidents of violence by
suggesting that the children were asleep or playing outdoors. Studies have shown that
despite mothers' efforts to shield their children from violence, 68 to 87% of incidents of
partner abuse are, in fact, witnessed by children (49). Parental
underestimation of children's distress symptom's has been clearly documented in the child
psychology literature (50,51). These parent-child discrepancies underscore the
need for investigators to interview children directly to accurately measure both the
frequency of exposure to violent events and assess their subsequent psychological
response. This presents another challenge in the field, as instruments to measure ETV
among young children (i.e., less than 8-9 years old) are even less well developed and yet
ETV during critical developmental stages may make younger subjects the most vulnerable (17,52).

Richters and Martinez (53) have
developed an instrument called 'Things I Have Seen and Heard' whichis a
15-question structured interview that probes young children's ETV and violence-related
themes in an age-appropriate format (i.e., grades 1 and 2). The interview consists of 15
pages, each describing a different form of violence. Response categories are depicted as
five stacks of balls, each with a different number of balls, ranging from none to four;
the columns are labeled sequentially from 'never' to 'many times'. Prior to
administration, children are taught how to circle the stacks to indicate the frequency of
their exposure to each event. These authors report good 1-week test-retest reliability
(r=0.8 1) (40).

Fox and Leavitt (54) have developed an instrument utilizing
cartoon pictures which depict violent events and response categories are depicted as a
thermometer which the child uses to report frequency of exposure. This is the VEX-Rã ,
the Violence Exposure Scale for Children - Revised (Full Scale Version) which was revised
in 1995. However, validity and reliability data are not yet available.

A modified version of the My ETV instrument is being developed and
piloted among children ages 6-8 years (FJ Earls, personal communication) however
reliability and validity data are not yet available.

Historically, exposure to conflict and violence in
the home has been most widely assessed through the Conflicts Tactic Scale (CTS) which has
been recently revised (55).

Whilethis is a widely used, reliable, and validated measure of domestic
conflict, several limitations have more recently been pointed out in the literature
regarding this developed a 10-item Women's instrument (56,57,58). The CTS
details a hierarchy of potential responses to family conflict ranging from reasoning to
verbal and/or physical aggression. Interpersonal conflict can be scored on three scales:
Reasoning Scale (RS), Verbal Aggression Scale (VAS) and the Physical Aggression Scale
(PAS). An Overall Violence Index (OVI) which sums all the component items from the PAS
will be obtained. The CTS will measure lifetime prevalence and prevalence over the last
year.

Qualitative research in women battering has revealed battering to be an
enduring traumatic, and multidimensional experience conceptually distinct from episodic
physical assault and more appropriately characterized as a chronic epidemiology (59).
Battering is not only associated with the pain and injury from physical assault, but
ongoing psychological degradation, sustained fear, diminished power and control, and loss
of identity and self-esteem. Measuring only discrete physical events fails to ascertain
the chronic vulnerability of the battering experience (60). Smith and
colleagues have Experiences with Battering (WEB) Scale which focuses on the chronic
psychological nature of battering which shapes women's behaviors, views of self, and
beliefs in the controllability of their lives (60). Domains include the
"perceived threat" or constant fear and danger women experience in their
relationships with abusive partners; they live in fear of future harm.
"Managing" represents a pattern of chronic behavior used in trying to prevent
the abusive partner from being violent and abusive; this is accompanied by the feeling of
"walking on eggshells". The third domain, "altered identity" reflects
battered women's changing self concept and loss of self that follows from the negative
images of themselves batterers reflect back to them. "Disconnection", the fourth
domain, represents battered women's largely futile efforts to establish intimacy with
their partners. "Entrapment" represents the disempowerment which reflects the
women's loss of power. These authors demonstrated high internal consistency and
reliability and good construct validity.

Exposure to community-level violence
impacts all racial and ethnic groups although poor minority youths are disproportionately
affected (59,60). Nationally, violent crime rates are associated with economic
inequality and racial residential segregation (i.e., racial inequality) (61).
Child maltreatment also is highly correlated with lower-SES (62). Although
violence crosses all social boundaries, it is not uniformly distributed in all classes.
Violence in the home is more prevalent in poor, minority, undereducated populations (63).
Thus, chronic ETV may be considered as a pervasive environmental stressor imposed on an
already vulnerable population of children and families (64).

The prevalence and mental and physical
health consequences of ETV are a topic of a growing number of research initiatives.
Historically, research on the health effects of social and political violence has
typically centered on direct exposure of individuals to violent acts (65,66,67)
which were often discrete catastrophic events (i.e., sniper attacks) (68). More
recently, investigators have focused on large population studies to explore the effect of
living in a violent environment, with a chronic pervasive atmosphere of fear and the
perceived threat of violence, on health outcomes (69,70,71). A growing body of
research explores potential adverse psychological consequences on children growing up in
chronically violent neighborhoods and homes (72,73). What are notably missing,
are studies that examine the possible adverse implications growing up in a violent
environment may have on physical health, and specifically chronic disease expression,
morbidity, and management in children.

Earlier research and theory on posttraumatic stress disorder (PTSD) (74),
children exposed to discrete catastrophic events (i.e., sniper attacks) (75),
children exposed to political violence and war (76), and children exposed to
domestic violence (77,78) suggest that a number of domains of cognitive,
social, emotional and psychophysiological functioning are significantly affected by
exposure to violence (e.g., depression, withdrawal, fear, anxiety, affect disregulation,
dissociative reactions, and intrusive thoughts). Studies of school-age children in
domestic violence shelters have described clinical levels of trauma-related stress
consistent with posttraumatic stress symptomatology including repetitive nightmares,
exaggerated startle response, inability to focus attention, and intrusive thoughts and
memories related to the violence (79,80). Descriptive studies of children
following a sniper attack on a playground (81) and children who were kidnapped
from their school bus and buried alive (82) reported maladaptive behavior
including reduced involvement with the external world, constricted affects, fewer
interests, and estrangement. Investigators have consistently documented problematic
development in school-age children exposed to domestic violence (83).
Specifically, such at-risk children are found to have increased rates of both
internalizing and externalizing behavior problems, lower self-esteem, and more
difficulties related to school relationships and academics (25,48). Only
recently, researchers are beginning to document similar adverse developmental sequelae
among preschool-age children of battered mothers (84).

Fewer systematic studies of the impact of community violence on child
development are available. Richters and Martinez have found significant associations
between childrens' (aged 6 to 10 years) reports of witnessing acts of violence in
communities around Washington DC and psychological distress, depression, and maladaptive
behavior (40). Osofsky and colleagues (85,86) found similar
increased likelihood of psychopathology and maladaptive behaviors among exposed
school-aged children living in a high crime urban environment around New Orleans,
Louisiana. One community study of urban adolescents found an increased rate of
posttraumatic stress disorder among the exposed youth (87). These studies
support an association between community violence exposure and negative impact on
childhood psychological well-being.

Social support has repeatedly been shown to
buffer the association between psychosocial stress and both physical and psychological
morbidity (88). Parents who are worried about their child's safety in the
neighborhood due to drugs and crime may keep their children indoors and otherwise restrict
their social behavior, and thus their ability to develop or use support networks may be
compromised (89). Psychopathology (e.g., PTSD, depression) may prevent the
child from forming relationships that are necessary to promote normal social development.
Isolation from social networks, support groups, and extended family is also associated
with violence in the home (i.e., child abuse, domestic violence) (90,91).Social
isolation in general has been linked to an array of adverse health outcomes (92)and physiologic effects such as altered immunologic functioning (93). The
instability and social isolation documented in abusive families may influence health
outcomes as well. Fear of crime in the community fosters a distrust of others and can
contribute to social isolation (94). In turn, social mistrust has been linked
to mortality. Kawachi and others (95) have utilized per capita social trust as
a marker of social cohesion and disinvestment in social capital within communities across
the United States. These investigators found that level of social trust was inversely
associated with total mortality, as well as rates of death from coronary heart disease,
malignant neoplasms, and infant mortality.

It is clear that violence is related to factors that limit formation of
social networks. These additional supports may be especially important to health and
well-being in inner-city populations faced with cumulative effects of many ecological risk
factors (i.e., poverty, low education, poor housing, etc.). It may be that violence
impacts health and well-being in through impact on social networks and social capital.
This warrants further study.

Health beliefs, in particular the belief
that one is susceptible, that the consequences of disease could be serious, and that
taking the recommended action results in greater benefit than cost, have consistently been
associated with health behavior (96). Given the above discussion, it seems
reasonable to speculate that those living with the pervasive threat of violence in their
lives may develop a distorted view of the world, including the priorities given to their
chronic illness. There is increasing evidence that health behaviors are adversely
influenced by environments that include high levels of violence and by daily life
experiences in unpredictable environments. Children exposed to high levels of violence in
the community and in the home (97,98,99) are more likely to develop a
foreshortened sense of the future, with a fatalistic outlook that may undermine their
ability to invest in the future by complying with a prescribed treatment regimen for
chronic medical conditions for example. Exposure to community violence may affect impulse
control and risk-taking behavior (100,101). Current theory holds that people
repeatedly exposed to aversive events they cannot predict or control may learn to become
helpless (102). DuRant and colleagues (103) examined the
relationships between exposure to community or intrafamilial violence and depression,
hopelessness, and purpose in life among black adolescents living in or around public
housing developments. These authors found that higher current depression and hopelessness
and lower purpose in life were significantly associated with the reported higher frequency
of exposure to, or victimization by, violence in their lifetime. The relationship among
violence exposure, feelings of hopelessness or lack of control, and adherence with medical
therapy, to date remains unexplored.

Studies of the association between violence
exposure and quality of life are scarce. In one community study of elderly Americans, fear
of victimization and concern for personal safety accounted for the greatest percent of
variance in quality of life between low-income black adults and whites (104).
We could not find studies that examined this question in children. Mechanisms that mediate
this association have not been characterized.

Many studies have found psychosocial correlates of increased healthcare
utilization among adults and children. Examining the 1988 child health supplement to the
NHIS, Angel and Angel (105) found that poverty was associated with greater risk
of emotional/behavioral problems, which in turn was a highly significant predictor of
frequency of medical care visits unrelated to mental health complaints. Others have found
that parental mental health, family conflict and determinants of life stress contribute to
healthcare use among children (106,107). Here, too, few studies have directly
examined the association between violence exposure and healthcare utilization. Koss et al.
(108) found that women who were victims of domestic or stranger violence,
compared with nonvictims, made physicians visits twice as frequently and had outpatient
costs that were 2.5 times greater during the index year following documented
victimization.

23. Straus MA. Children as witness to marital violence: a risk factor for lifelong
problems among a nationally representative sample of American men and women. Presented at
the Ross Roundtable on Children and Violence, Washington, DC, 1991.

103. DuRant R, Getts A, Cadenhead C, Emans SJ, Woods ER. Exposure to violence and
victimization and depression, hopelessness, and purpose in life among adolescents living
in and around public housing. Develop Behav Pediatr 1995; 16:233-237